Cancer care Oral care-Guidelines TD-7



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Oral Care Guidelines for Cancer Care Directorate

|Version: |1.0 |

|Approval Committee: |Cancer Care Governance |

|Date of Approval: | |

|Ratification Committee (Level 1 documents): | |

|Date of Ratification (Level 1 documents): | |

|Signature of ratifying Committee Group/Chair (Level 1 documents): | |

|Lead Job Title of originator/author: |Lead Nurse BMT |

|Name of responsible committee/individual: |Cancer Care Governance |

|Date issued: |19/11/2013 |

|Review date: |19/11/2016 |

|Target audience: |All cancer care staff |

|Key words: |Mucositis, stomatitis, chemotherapy bone marrow / stem cell |

| |transplant, oral hygiene |

|Main areas affected: |Cancer Care wards |

|Summary of most recent changes: |Documented reviewed, use of MUST scoring and Bristol stool |

| |chart added. Drugs updated. Cocaine mouthwash removed. |

| |Diamorphine replaced with morphine. Scoring chart updated and |

| |reformatted. Some drugs removed as no longer available. |

|Consultation: |Consultant Nurse for chemotherapy, ward managers, pharmacy, |

| |Cancer Clinical Nurse Specialists. |

|Equality Impact Assessments completed and policy promotes Equity |19/11/2013 |

|Number of pages: |14 |

|Type of document: |Level (enter 1 or 2) |

|Is this document to be published in any other format? (If so state | |

|format and give name of the responsible person) | |

The Trust strives to ensure equality of opportunity for all, both as a major employer and as a provider of health care. This Oral Care Guidelines for Cancer Care Directorate has therefore been equality impact assessed by the Cancer Care Governance Group to ensure fairness and consistency for all those covered by it, regardless of their individual differences.

Contents

|Paragraph |Page |

| |Executive Summary/ Policy Statement/Flowchart | |

|1 |Introduction | |

|1.2 |Scope | |

|1.3 |Aim/Purpose – outline objectives and intended outcomes | |

|1.4 |Definitions – if necessary | |

|2 |Related Trust Policies | |

|3 |Roles and Responsibilities or Duties | |

|4 |eg procedures to be followed | |

|5 |Implementation (including training and dissemination) | |

|6 |Process for Monitoring Compliance/Effectiveness of this policy | |

|7 |Arrangements for Review of this Policy | |

|8 |References | |

| | | |

|Appendices | |

|Appendix A |Daily oral assessment guide | |

|Appendix B |Individual Interventions | |

|Appendix C | | |

| | | |

| | | |

| | | |

Executive Summary

The incidence of oral mucositis in the cancer setting is very high. It can be expected to occur in at least 40% of patients undergoing chemotherapy to treat a solid tumour and as many as 70% of patients undergoing haematopoietic stem cell transplantation (Sonis 2004). Kostler et al (2001) estimate that as many as 97% of patients receiving irradiation with or without chemotherapy for head and neck cancers will suffer from some degree of oral mucositis.

1 Introduction

1 This policy deals with heamato-oncology and solid tumour oncology inpatients and outpatients who are at risk of developing oral problems due to either receiving chemotherapy or radiotherapy for the control of disease, who are undergoing palliative care, or are having intensive chemotherapy and / or bone marrow / stem cell transplant, who as a result are highly likely to develop mucositis and / or stomatitis.1,2

2 The Guidelines are based on an extensive literature search of the available evidence, best practice from similar units and the newly released Mouth Care Guidance and Support in cancer and Palliative Care 2012, UK Oral Mucositis in Cancer Group.

3 The Guidelines apply to all nursing and medical staff caring for patients undergoing these procedures.

2 Related Trust Policies

Screening of adults for malnutrition policy 2012

Cancer Care Infection prevention and therapy protocols 2010

Diarrhoea and/or vomiting: Policy for the management of unexpected /unexplained cases 2010

3 Roles and Responsibilities

All staff that are responsible for care of patients undergoing intensive chemotherapy within the ADULT setting are responsible for following these guidelines.

Ward and Department Managers are responsible for ensuring that all possible measures are taken to reduce the spread of infection to patients. All managers are responsible for ensuring that these guidelines are implemented in their areas and for ensuring all staff who work within the area adhere to the principles at all times. All managers are responsible for ensuring that staff have access to up to date training to enable them to adopt safe working practices at all times and are appropriately trained to minimise risks to themselves and others.

Consultant Medical Staff are responsible for ensuring their junior staff read and understand these guidelines and adhere to the principles contained within this document at all times.

Divisional and Care Group Management Teams are responsible for monitoring implementation of these guidelines and for ensuring action is taken when staff fail to comply with these guidelines.

Non-compliance with a Trust Policy, Procedure, or Protocol may result in disciplinary action.

4 PRINCIPLES

4.1 Increased Risk Factors for Mucositis

• Intensive chemotherapy regimens / bone marrow transplant/ leukaemia1,3

• Elderly and children4

• Deficits in self care ability

• Altered fluid or nutritional status (dehydration, malnutrition)5,2

• Receiving certain medications, particularly steroids and other immunosuppressive drugs

• Exposed to additional stressors (alcohol, tobacco, drugs, oxygen therapy)2,8

• Liver / renal impairment

• Previous experience of mucositis

• Graft versus Host Disease

• Cancer of the Head and Neck

• Impaired immunity

• Receiving Stomatotoxic drugs6

4.2 List of stomatotoxic drugs6

Amsacrine

Bleomycin

Busulphan Capecitabine

Chlorambucil

Cladrabine

Cyclophosphamide (high dose)

Cytarabine (high dose)

Daunorubicin (all forms) Dacitinomycin Docetaxel (Taxotere) Doxorubicin Epirubicin

Erlotonib

Etoposide

5-Fluorouracil

Gemcitabine

Hydroxycarbamide

Idarubicin

Ifosfamide

Irinotecan

Melphalan (high dose)

Methotrexate

Mitomycin C

Mitoxantrone

Mitotane

6 Mercaptopurine

Oxaliplatin

Paclitaxol (Taxol)

Panitumumab

Pazopanib

Pemetrexed

Raltitrexed (Tomudex)

Sorafenib

Sunitibnib

Streptozocin

Temsirolimus

Temozolomide

Thioguanine

Thiotepa

Topotecan

Vinblastine

Vincristine

Vindesine

Vinorelbine

ACTION REQUIRED

4.3 All patients should have an oral assessment undertaken by a registered nurse / trained Health Care Assistant on admission to the unit using the assessment sheet in Appendix A. The assessment is also undertaken -

a) To identify usual oral care routine

b) To identify the advice/care required to maintain and promote individual oral care.

4.4 The Oral Assessment Guide should be implemented for all patients and assessment undertaken daily. (Appendix A)7 Patients who have developed severe mucositis should be assessed each shift.2

4.5 Teeth should be cleaned four times a day8 with a soft toothbrush12 and fluoride toothpaste. The mouth should be rinsed thoroughly with a sodium chloride 0.9%9 mouthwash after . Patients should then rinse with 1ml of nystatin suspension and then swallow this. They should avoid drinking and eating for 20 minutes afterwards.

Antifungals and antivirals should be prescribed for those patients at high risk as described in the Cancer Care Infection prevention and therapy protocols 2010.

Caphosol® (4-10 times a day) could be considered for patients at high risk of mucositis. This should start on the first day of chemotherapy or first day of radiotherapy. MuGard® can also be considered as a mucosal protectant. There should be a one hour gap after using for maximum effect.

NB Neither Caphosol® or MuGard® are available through pharmacy and has to be ordered via ward budgets through medical appliances.

4.6 Adequate oral fluid intake and self-care measures should be encouraged and the necessary information education and mouthwashes provided to meet their individual requirements.2

4.7 The level of care required should be discussed with the patient and any assistance required identified.

4.8 Dentures should be

a. Removed each time the patient undertakes their mouth care and brushed and rinsed with water, prior to putting back into their mouths.

b. Soaked overnight in a denture solution15, cleaned with a brush and rinsed prior to putting back into their mouths. It is advisable for patients to leave their dentures out overnight.12

4.9 Prior to commencing treatment (where possible)

a. Patients having high dose chemotherapy, head and neck patients, and transplant patients should see a dentist7,9 This should be discussed with their Consultant, as they may need prophylactic antibiotics to be prescribed.

b. Patients identified at increased risk of mucositis should be referred to the dietician2.

4.10 Following completion of treatment patients should be encouraged to visit the dentist on a six monthly basis. For transplant patients this needs to be after permission is given from the Consultant in charge of their care.

4.11 Advise patients not to use commercial mouthwashes.

4.12 Encourage patients to stop smoking.

5 Implementation

The updated guidelines will be disseminated to clinical staff by managers of those areas. There is a training DVD on how to inspect the oral cavity which can be viewed on line at ukomic.co.uk

6 Process for Monitoring Compliance/Effectiveness

Regular audit will be undertaken of patients’ notes to ensure that this policy is used to assess oral hygiene needs of patients undergoing intensive chemotherapy and / or bone marrow / stem cell transplantation.

The purpose of monitoring is to provide assurance that the agreed approach is being followed – this ensures we get things right for patients, use resources well and protect our reputation. Our monitoring will therefore be proportionate, achievable and deal with specifics that can be assessed or measured.

Any identified areas of non-adherence or gaps in assurance arising from the monitoring of this policy will result in recommendations and proposals for change to address areas of non compliance and/or embed learning. Monitoring of these plans will be coordinated by the group/committee identified in the monitoring table.

Key aspects of the procedural document that will be monitored:

|What aspects of compliance |What will be |How and how often will |Detail sample size |Who will co-ordinate and|Which group or report |

|with the document will be |reviewed to |this be done |(if applicable) |report findings (1) |will receive findings |

|monitored |evidence this | | | | |

|Use of the scoring forms |Patients nursing |As part of ward managers| |Ward managers |Cancer governance |

| |notes |rounds | | | |

1) State post not person.

7 Arrangements for Review of the Policy

The policy will be reviewed in 2 years time.

8 References

REFERENCES

1. McGuire DB. Yeager KA. Dudley WN. Peterson DE. Owen DC. Lin LS. Wingard JR. Acute oral pain and mucositis in bone marrow transplant and leukemia patients: data from a pilot study. Cancer Nursing. 21(6):385-93, 1998 Dec.

2. National Cancer Institute. Oral complications of chemotherapy and Head/Neck radiation. Monograph on the Internet. Bethseda:NCI

nci.cancertopics/pdq/supportivecare/oralcomplications/healthpromotion 2005

3. Stiff P. Mucositis associated with stem cell transplantation: current status and innovative approaches to management. Bone Marrow Transplantation. 27 Suppl 2:S3-S11, 2001 May.

5. Sonis ST. Oster G. Fuchs H. Bellm L. Bradford WZ. Edelsberg J. Hayden V. Eilers J. Epstein JB. LeVeque FG. Miller C. Peterson DE. Schubert MM. Spijkervet FK. Horowitz M. Oral mucositis and the clinical and economic outcomes of haematopoietic stem-cell transplantation. Journal of Clinical Oncology. 19(8):2201-5, 2001 Apr 15.

6. Quiltz, R. Oncology Pharmacotherapy: Modulation of chemotherapy – Induced Mucositis. Cancer Control Journal, 2(5) Sept/Oct. 1995.

7. Feber T. Mouth care for patients receiving oral irradiation. Professional Nurse. 10(10):666-70, 1995 Jul.

8. Oral Hygiene Protocol. Manchester christie.nhs.uk/profinfo/departments/nursing/nursing_developments/developments/oral_hygiene.pdf

9. National Cancer Institute. Oral and dental management prior to cancer chemotherapy. Monograph on the Internet. Bethseda:NCI

nci.cancertopics/pdq/supportivecare/oralcomplications/healthpromotion 2005

10 Porta C. Moroni M. Nastasi G. Allopurinol mouthwashes in the treatment of 5-fluorouracil-induced stomatitis. American Journal of Clinical Oncology. 17(3):246-7, 1994 Jun.

11 UHS Cancer Care Infection and Prevention Policy 2010

12. Sweeney P Oral Hygiene in Oral Care in advanced Disease ed. Davies A, Finlay I 2005 Oxford University Press.

13Pfeiffer P, Madson EL, Hanson O, et al. Effective prophylactic sucralfate suspension on stomatitis induced by cancer chemotherapy: a randomised, double-blind crossover study. Acta Oncol, 1990:29:171-173

14 Meechan J, Oral Pain, in Oral Care in advanced Disease ed. Davies A, Finlay I 2005 Oxford University Press.

15 UKOMiC. Mouth care guidance and support in cancer and palliative care 2012. ukomic.co.uk accessed April 2013.

Appendix 1

Oral Assessment Guide

|Category |Normal |Mild to moderate change |Moderate to severe change |

| |No changes |Score 2 for each response below. |Score 3 for each response below. |

| |Score 1 for each response below. | | |

|Voice |Normal (1) |Deeper or raspy (2) |Unable to talk (3) |

|Swallow |Normal swallow (1) |Some pain on swallow (2) |Unable to swallow (3) |

|Lips |Smooth, pink and moist (1) |Dry or cracked (2) |Ulcerated or bleeding (3) |

|Tongue |Pink and moist with papillae present (1) |Coated or loss of papillae with shiny appearance with or without redness (2) |Blistered or cracked (3) |

|Saliva |Watery (1) |Thick or ropey (2) |Absent (3) |

|Mucous membranes |Pink and moist (1) |Reddened or coated without ulceration (2) |Ulcerations with or without bleeding (3) |

|Gingiva |Pink and firm (1) |Oedematous (2) |Spontaneous bleeding (3) |

|Teeth |Clean or no debris (1) |Plaque or debris in localised areas (2) |Generalised plaque or debris along gum line. (3) |

|Category |Normal, no changes |Mild to moderate change |Moderate to severe change |

| |Score 1 for each below |Score 2 for each below |Score 3 for each below |

|Voice |Normal |Deeper or raspy |Unable to talk |

|Swallow |Normal swallow |Some pain on swallow |Unable to swallow |

|Lips |Smooth, pink and moist |Dry or cracked |Ulcerated or bleeding |

|Tongue |Pink and moist with papillae present |Coated or loss of papillae with shiny appearance with or without redness |Blistered or cracked |

|Saliva |Watery |Thick or ropey |Absent |

|Mucous membranes |Pink and moist |Reddened or coated without ulceration |Ulcerations with or without bleeding |

|Gingiva |Pink and firm |Oedematous |Spontaneous bleeding |

|Teeth |Clean or no debris |Plaque or debris in localised areas |Generalised plaque or debris along gum line |

(to be printed off and laminated, a copy of this should be kept in individual patient records folders on the wards so that it can be used at the patient bed side)

|Date and Time of assessment |Voice score |Swallow score |

|Healthy |Brush teeth with soft tooth brush 4 x day | |

|Mouth / no mucositis |+ | |

| |Use Sodium Chloride 0.9% mouth2 wash 5mls QDS| |

| |+ | |

| |nystatin suspension 1 ml QDS (best used after| |

| |meals) | |

| |Continue with the standard mouthcare |- Introduce Benzydamine 0.15% mouthwash (Diflam®), 15 mls |

|Mild – Moderate |protocol. |every 1½-3 hrs. May be diluted 50/50 with water. NB not to |

|Mucositis | |be used in head and neck patients. Warn patient that it may |

| |If dry mouth consider saliva stimulants, |sting for a few seconds. |

| |replacement gel / spray and increasing fluid | |

| |intake (See notes in individual interventions|- If has localised ulcer – consider using orabase® paste or |

| |for recommendations) |bonjela®. |

| | | |

| |If oral thrush notify Dr and consider |- Try soluble paracetamol gargles. 1gram QDS maximum dose |

| |increasing nystatin to 3-5 mls QDS | |

| |Fluconazole p.o. may be required (may be on a|-Add in either Oxetacaine & Antacid suspension 5 ml QDS |

| |systemic antifungal already) |rinse (5 minutes is the optimum time)14 and then spit out or|

| | |swallow if needed for oesophageal pain. |

| |Ensure MUST scoring is maintained and |Or |

| |dietetic referral made as appropriate |- Add in sucralfate suspension, 5ml QDS– need not be |

| | |swallowed if patient has sore mouth only. |

| |Commence food chart | |

|Moderate to Severe mucositis |Continue with standard mouth care protocol. |- Consider morphine infusion. |

| |If unable to brush teeth, try using a foam | |

| |sponge instead. NB not as effective as tooth | |

| |brushing. Patients should be encouraged to | |

| |use a brush where possible. Consider using a |Ensure adequate fluid intake. |

| |TePe® brush available from dentists. | |

| |+ |Think about using a pain-scoring chart to monitor |

| |Increase sodium chloride 0.9% mouthwashes to |effectiveness of measures taken. |

| |1-2 hourly (5mls) | |

| |+ | |

| |continue antifungal agents | |

| |+ | |

| |Ensure fluid balance chart commenced. | |

| |+ | |

| |Ensure food chart commenced. | |

**NB All medications, mouthwashes need to be prescribed by a doctor or by a qualified independent non medical prescriber**

Adapted from Christie Hospital Protocol, Manchester8

Appendix 2

Individual Interventions

LIPS/CORNERS OF MOUTH

• Use aquagel as a moisturiser for lips. Ensure that each patient has his or her own new tube for personal use. NB Soft yellow paraffin increases the risk of aspiration12 and should not therefore be used.

• Observe for herpes simplex and refer to Dr immediately. Commence Aciclovir cream 5% as prescribed (5 x a day for 5-10 days).10

CANDIDA/INFECTION

• Observe for white patches or creamy white areas. These could be an indication of infections or thrush (pseudomembranous candidosis is the most common fungal mouth infection where white lesions can be easily removed).16

• Observe for any signs of halitosis

• Refer to Dr for appropriate anti-fungal/antibacterial/antiviral agents.

TONGUE

A. COATED

• Very gently brush tongue with soft toothbrush3 or tongue scraper.

• Encourage good regular mouth care.

• Increase fluid intake – a likely cause is dehydration!

• If drinking plenty it might be due to very sugary drinks, try a low sugar version.

• Check to see if patient’s nose is blocked as mouth breathing makes this worse.

• A ‘hairy’ tongue is associated with smoking and antibiotic use. Encourage patients to stop smoking.

B. BLISTERED/CRACKED

• Increase fluid intake, particularly water

• Initiate mouth care protocol for severe mucositis

• Ensure adequate analgesia given, especially prior to mealtimes.

DRY MOUTH (Xerostomia)

• Drink plenty of water, particularly whilst eating

• Increase use of sauces, gravies

• Consider use of crushed ice (use boiled water11 or sterile water only), frozen tonic water, artificial saliva, and sugar free chewing gum. Note if ice pops are consumed use sugar free juice. Patients often find sucking boiled sweets helpful. Sucking fruit such as pineapple chunks is not recommended as acid based products are associated with oral discomfort and demineralisation of the teeth16.

• Avoid citrus drinks if this causes further pain or discomfort.

In order of most effective

• Salivary stimulation using chewing gum (low sugar) qds16. This may be contraindicated in head and neck setting due to thickened secretions or the complete absence of any saliva which may increase the risk of choking.

• Parasympathominetic drugs (pilocarpine), which are effective against Xerostomia induced by drug treatment, salivary gland disease and radiotherapy, however with radiotherapy improvement may not occur for up to 12 weeks. Recommended dose is 5mg t.d.s. NB. This will need to be prescribed with caution due to many drug interactions.16

• Saliva replacements of which mucin based products are the most effective and gels are thought to be better tolerated than sprays.16 Oral Balance (Biotene ®), or Glandosane® spray.

• Ensure thickened secretions are removed – steam inhalation or saline nebulisers can loosen secretions and help expectoration. Sodium bicarbonate mouthwash (1 teaspoon of sodium bicarbonate in 1 pint of cooled boiled water) made fresh daily and used every 3-4 hours may assist in clearing thickened secretions. There is some evidence to suggest that the use of sodium bicarbonate may affect the pH of the mouth and interfere with mucosal healing; therefore it should be used with caution.16

TEETH/DENTURES

• Ensure any patients with loose teeth, ill fitting dentures or caries are referred to Dental department7, 9

• Advise patient to clean dentures 4 times a day, including underneath the dental plate. 2,12

• Advise patient to remove dentures overnight and soak in a weak chlorhexidine solution.12

• NB do not use an ordinary toothpaste as it damages denture surface.12

SWALLOWING/CHEWING

• Consider nutritional impact. Complete MUST scoring, Commence nutritional care plan. Ensure referral to dietician5,2.

EATING AND DRINKING

• If any deficits in this area patients should be commenced on a fluid balance chart, a food chart and be referred to the dietician.

DIARRHOEA

• If patients develop diarrhoea this could be due to gut irritation following their treatment. A stool sample should be sent to ensure that there is no infectious cause.

• A fluid balance chart needs to be maintained and all diarrhoea should be measured and recorded. If patient is post an allogeneic transplant this could be caused by graft versus host disease. It is important that frequency, quantity and colour of diarrhoea is recorded so that the progress of the disease can be measured and monitored, as well as any response to treatment. Use Bristol stool chart.

• Fluid loss through diarrhoea can exacerbate the symptoms in the mouth.

SORE THROAT

• Encourage patients to drink plenty as this helps to relieve pain caused by dryness.

• Encourage a soft diet, with plenty of sauces as this makes it easier for patients to swallow.

• If there are white patches on examination of the patients’ throat a swab of the mouth and throat should be sent for both microbiology and virology (virology samples need to go in a special medium pot which should be kept in the fridge).

• If patient is post transplant and has a prolonged sore throat a viral swab should be sent off to check for any unusual viral infections such as HSV or HHV6, adenovirus etc.

PAIN

• Soluble paracetamol mixture (1gram in 20mls) Give half an hour before meals and before bedtime. Do no exceed maximum daily dose and do not take with other medicines containing paracetamol. Please record on the observation chart if paracetamol has been administered as well as the drug chart.

• Oxetacaine and antacid suspension – can be rinsed and spat out or swallowed. Can be especially helpful to swallow in patients with oesophageal pain. Optimum rinsing time is 5 minutes.

• Benzydamine 0.15% (Diflam) mouthwash – has a local anaesthetic effect. Can be used every 11/2 – 3 hours. Can cause stinging and has quite a strong flavour. Gargle the mouthwash as this will lead to numbness. Can be diluted 50/50 with water. If given before meals don’t gargle. Avoid hot food. As tolerance can develop use for 7 consecutive days only. Not to be used instead of Sodium Chloride 0.9%. Not to be used in head and neck patients undergoing radiotherapy.

• Sucralfate Suspension 1g/5ml, to be used after meals. May have some prophylactic value and promote healing / reduce severity of mucositis. Use as a mouthwash (swish and spit out) to relieve oral discomfort, if patient has sore mouth only. Can be swallowed if patient also has sore throat.

• Controlled systemic analgesia –

- Morphine Sulphate oral solution or Morphine continuous intravenous infusion.

Monitor bowel function, as aperients may be required.

Needs to be titrated according to pain experienced.

Remember to administer anti-emetics as well.

GRAFT VERSUS HOST DISEASE OF THE MOUTH

• Need to keep mouth moist, use interventions for dry mouth.

• Monitor carefully for infections

• Monitor carefully for soreness and ulceration – can use orabase paste to help with pain control particularly if there are small ulcers. This will provide a protective paste over the ulcers.

• Steroid mouthwashes may have some benefit.

- Prednisolone 5mg soluble tablets in 10mls sterile water four times a day.

- Or Betamethasone 500micrgrammes in 20mls sterile water four times a day

- Or hydrocortisone 2.5 mg buccal tablets four times a day.

• Ciclosporin mouthwashes 5ml orally three times a day (Use the 100mg/ml oral solution)

HIGH DOSE METHOTREXATE

• To help reduce the very sore mouth associated with high dose methotrexate patients can be advised to suck ice whilst infusion in progress.

BLEEDING MOUTH.

• Tranexamic acid mouthwashes can be used to help control bleeding in the mouth. Use injection 5 mls diluted with 5 mls of saline q.d.s.

• Not to be used in transplant patients.

APPENDIX 3

EQUALITY IMPACT ASSESSMENT TOOL - To be completed for all new/revised policy, procedural and guideline documents.

Equality Impact Assessments (EQIAs) are a way of examining new policy* documents to see whether they have the potential to affect any one group of people more or less favourably than another. Their purpose is to address actual or potential inequalities resulting from policy development. The duty to undertake EQIAs is a requirement of race, gender and disability legislation.

The word ‘policy’ is taken to mean all procedural documents i.e.: Policy, Procedure, and Guideline. (This does not include Patient Information)

|Document Title |Oral Care Guidelines for Cancer Care |Version |

| | | |

|Is this a new or revised document? |Revised Document |

|Area to which document relates Specify whether Trust|Cancer Care |

|wide or, Care Group. Name Care Group | |

|Name of person completing Assessment |Nikki McKeag |

STAGE 1 – INITIAL SCREENING

This stage establishes if the proposed change will have an impact from an equality perspective on any particular group(s) of people. See guidance notes on completion.

|Does the document affect one group more |Positive Impact |Negative Impact |Comments - Give details of concerns and evidence in the boxes |Impact Level |

|or less favourably than another on the |Y/N/Neutral |Y/N/Neutral |below |N/L/M/H |

|basis of any of the strands of diversity?| | | | |

|Disability |No |No | | |

|Gender |No |No | | |

|Sexual Orientation |No |No | | |

|Race & Ethnicity |No |No | | |

|Religion or Belief |No |No | | |

|Culture |No |No | | |

|Other e.g. Mental Health, Geographic |No |No | | |

|factors, Economic factors... | | | | |

Level of impact:

Taking into account the impact level for each group, circle one of the words in the boxes below to identify the overall impact level:

| |LOW | | |

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Oral assessment scoring and monitoring sheet

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